DTC Formulary Submission and IPU Application Templates
NSW TAG has developed templates and accompanying tools to assist hospital Drug and Therapeutics Committees in systematic, evidence-based review and decision-making about applications for new medicines or new indications in accordance with NSW Health Policy Directive PD2016_033: Approval Process of Medicines for Use in NSW Public Hospitals
The formulary submission and IPU application template were updated in December 2009 based on feedback from the NSW TAG membership and clinicians working in NSW public hospitals. The updates included prompts for the inclusion of PBAC public summary documents, where relevant, and the acknowledgement of the multidiscplinary nature of these forms.
Templates and Tools
Information for DTCs about the use of the tools and templates
Updated June 2019
Device containing Medicines Submissions:
For all submissions/applications to DTC:
High Use IPU Medicines
In general, hospitals have been recommended to consider adding to formulary those medicines which have had more than three IPU applications approved. However many of these medicines are expensive and use requires ongoing monitoring to ensure there are no cost blowouts. Some hospitals have developed streamlined IPU forms to facilitate DTC approval processes for these medicines but ensure that outcomes are monitored and DTC continues to have oversight of the medicines use.
Below are examples of streamlined IPU forms from St Vincent’s Hospital:
- Azithromycin for Lung Transplant Patients [PDF]
- Baxter Bottles [PDF]
- Everolimus [PDF]
- Levosimendan [PDF]
- Pulmonary Arterial Hypertension [PDF]
- Rituximab in Lung Transplant patients [PDF]
Other Resources for DTC decision makers
- Checklist for Endorsement of Medication Charts Forms and Medication-related Protocols/Guidelines 2018
- Achieving effective medicines governance: Guiding Principles for the roles and responsibilities of Drug and Therapeutics Committees in Australian public hospitals, November 2013.
- Managing Medicines Access Programs : Guiding Principles for the governance of Medicines Access Programs in Australian hospitals, 2018.
- Table 1: Suggested Medicines Access Program Cost Recovery Fee Schedule
- Overseeing biosimilar use: Guiding Principles for the governance of biological and biosimilar medicines in Australian hospitals. Version 2, September 2016.
- Position Statement for the use of Complementary and Alternative Medicines, May 2015.
- Rethinking Medicines Decision Making : Guiding Principles for the quality use of off-label medicines.
- Achieving Effective Medicines Governance: Guiding Principles for the roles and responsibilities of Drug and Therapeutics Committees in Australian public hospitals.
- Appendix 6: Drug and Therapeutics Committees Checklist (version 1).
In addition the NPC has released an e–Learning package that considers the legal and ethical aspects of local decision-making about the funding of medicines and treatments.